Tocilizumab Versus Methylprednisolone in the Cytokine Release Syndrome of Patients With COVID-19

In December 2019, several patients were diagnosed with pneumonia of undefined etiology in
Wuhan, China. A few days later, a virus was identified as the etiologic agent. It was a new
beta coronavirus that received the name of Severe Acute Respiratory Syndrome Coroinavirus
(SARS-COV-2).

The disease quickly spread to the Wuhan region and in March reached northern Italy and soon
across Europe. On March 14, the World Health Organization declared that COVID-19 had acquired
seriousness and spread to be defined as a pandemic.

Since then, COVID-19 has challenged the ability of rich countries to meet the demand for
beds, especially ICU beds, and it has also challenged science in search of effective
treatment, while in record time research centers begins testing with a vaccine.

Although a significant percentage of patients with COVID-19 have a benign evolution, around
20% of cases the disease acquires sufficient severity from the point of view of lung
involvement to justify treatment in the ICU. In addition, around 5% of patients evolve with
extremely serious forms and are associated with a lethality of up to 60%. Some of these
patients demonstrated in studies alterations in cellular and humoral immunity compatible with
the cytokine release syndrome, an entity that has been described complicating the use of
antineoplastic drugs and viral infections.

At this moment several studies, some of them with conclusions already seek to identify
effective forms of treatment. Antiviral drugs such as Lopinavir-Ritonavir, which has already
been tested in a prospective randomized study and has not been shown to be effective. The
antiviral rendecivir was tested in a preliminary study brought a positive expectation and the
hydroxychloroquine in studies with small samples is the drug that currently meets the highest
expectations. None of these drugs, however, is effective in the case of the group of patients
who acquire severity as a result of what has been called a cytokine storm. In this case,
expectations are turned to interleukin antagonists and corticosteroids. Among the interleukin
antagonists the drug that meets the most expectations is Tocilizumab, an interleukin-6
antagonist that has proven efficacy in the cytokine release syndrome caused by antineoplastic
drugs. There are currently ongoing studies analyzing the role of tocilizumab and, at the same
time, and along the same line, corticosteroids are being tested. There is currently no
prospective randomized study examining the role of tocilizumab. Regarding corticosteroids,
the only evidence comes from a retrospective study involving 201 patients with COVID
pneumonia 19 and acute respiratory distress syndrome. This study showed an association
between corticosteroids and reduced risk of death (HR 0.38; p = 0.003).